5500-E 1 Student Records Request Form

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Name of Individual Requesting Records

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Maiden Name if Married

_________________________________________

Date of Birth

________________________________________

Address

I hereby apply to inspect and/or copy the following records (Please be specific).

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Reason for request:

________________________________________________________________________

Graduated? _____ Yes ______ No

Withdrew? (Month/Year) ________________________________

I would like my records mailed to: ________________

___________________________

Signature

___________________________ ___________________________

Mailing Address Date

FOR DISTRICT USE ONLY

APPROVED □

DENIED (FOR REASON[S] CHECKED BELOW)

□ Confidential disclosure □ Unwarranted invasion of personal privacy

□ Part of Investigatory Files □ Record not maintained by the District

□ Record of which the District is legal custodian cannot be found

□ Exempt by status other than the Freedom of Information Act (FOIL)

□ Other (Specify) _____________________________________________

___________________ __________________________ _________________

Signature Title Date

Notice: You have a right to appeal a denial of this application by contacting the Superintendent of Schools.

Approved by the Board of Education: 2/25/10

Revision approved by the Board of Education: 7/08/25